How Do Doctors Die?
Dr. Ed Friedlander is a clean-cut, 64-year-old pathologist practicing in Kansas City, Missouri. He does not look like a person who would have a tattoo. But square in the center of his chest, in bold ink, are these words: “No cpr.”
The tattoo isn’t a fashion accessory. It is there to reinforce what Dr. Friedlander has written in his living will: In the event of many medical emergencies, he does not want to be given cardiopulmonary resuscitation (cpr) or other life-prolonging procedures. Even if he is unconscious and the paramedic doesn’t know about the will, he can just read the tattoo.
It’s not that Friedlander doesn’t enjoy being alive. But his career in medicine has given him more knowledge than the average person about the realities of cpr and other emergency procedures. And all that knowledge has left him with little faith in those procedures. “In pathology, you think a lot about the end of life,” he said. “Nobody would ever accuse me of not loving life. … [But] when this thing stops beating, it’s time for me to move on.”
Friedlander says he never wants to receive what some doctors call “futile care.”
Dr. Ken Murray had a private practice of general medicine in Studio City, California, for 25 years until his retirement in 2006. In his 2011 online article, “How Doctors Die,” he defines “futile care” as what happens “when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life.” Murray says, “The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery ….”
Friedlander and Murray are not the only medical experts with a low opinion of these kinds of “futile care,” end-of-life treatments.
Doctors Opt Out
The average person frequently elects to receive all kinds of “futile care” for himself and even more so for a loved one. Finding himself in an emergency room after a crisis has struck, he is frightened and overwhelmed. If doctors ask if he would like “everything available” to be done, he is prone to say yes.
“Then,” Murray says, “the nightmare begins.”
“Sometimes, a family really means ‘do everything,’ but often they just mean ‘do everything that’s reasonable.’” The trouble is that people who are not medical experts usually don’t know what is reasonable in a given scenario and what is not. And doctors who are asked to do “everything available” generally do it—even when it is not reasonable.
Murray explains that part of the problem is the “unrealistic expectations” the general population has about “what doctors can accomplish.”
But many doctors themselves do not have any such “unrealistic expectations” about the capability of the medical establishment. As part of the ongoing Johns Hopkins Precursors Study, 765 doctors (with a mean age of 68) responded to a 1998 questionnaire asking what they would want done for themselves if they were suffering from irreversible brain damage or brain disease where they couldn’t recognize people or speak understandably, but did not have terminal illness.
The doctors were asked if they would want to receive the following procedures: cpr, mechanical ventilation, dialysis, chemotherapy, major surgery, invasive testing, nourishment from a feeding tube, blood transfusion, antibiotics and intravenous hydration.
Ninety percent of the doctors said if they were in such a grim end-of-life situation, they would not want cpr. About 87 percent said they would refuse mechanical ventilation, and the same number said they would refuse dialysis. Eighty-five percent said no to chemotherapy, and 81 percent opted out of all major surgery. About 79 percent said they would not want invasive testing, and 77 percent said no to being fed via a feeding tube. Seventy-four percent said they would not want blood transfusions. About 62 percent said no to antibiotics, and 59 percent said no even to intravenous hydration.
Those are some astounding numbers. Over the course of their careers, doctors have witnessed patients undergoing these very same procedures numerous times. Why don’t they want these methods used on themselves?
It’s not in spite of the fact that they have experience with these procedures—it’s because of it. The realities of these common medical practices have disillusioned the doctors.
Dr. Murray explains: “Doctors … know enough about modern medicine to know its limits. … For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.”
Despite having virtually unlimited access to medical care, doctors overwhelmingly hope to “go gently.”
Dr. Saul Blecker, assistant professor of population health and medicine at nyu Langone Medical Center, agrees with that logic: “Doctors see a lot of patients who are treated aggressively at the end of life, and often in ways that seem maybe too intense.” Blecker says if more people had understanding of the limitations of end-of-life care, “more people” would choose to “die a ‘good death.’”
If those who know the most about modern medicine have a bleak view of end-of-life treatments, why does the general population tend to see it differently?
‘I’m Not a Doctor, but I Play One on TV’
Part of the reason why the general population puts more trust in medical procedures than doctors do stems from how they are portrayed in the media.
Back in 1996, researchers from the Durham VA Medical Center examined the tv programs ER, Chicago Hope and Rescue 911 to see how many people on the shows benefited from cpr intervention. The conclusion was that 77 percent of patients were revived by cpr and were basically all better.
In real life, the number is a fraction of that. Overall survival rates are rarely compiled since researchers focus on specific demographic groups. Only 2 percent of adults of all ages who receive cpr after collapsing out-of-hospital fully recover, according to a 2012 study published in the Journal of the American Medical Association. Of the 15,300 Swedes of all ages who suffered cardiac arrest outside of hospitals from 1990 to 2011, just 10.5 percent were alive 30 days later. A 2009 study in the New England Journal of Medicine said that about 18 percent of seniors who receive cpr in a hospital survive to be discharged. And of those who do survive to discharge, fewer than half have a full recovery free of lasting complications.
While tv says almost 8 in 10 cpr patients spring back to good health and return to their lives, the reality is it is much lower.
Doctors know this reality far better than the rest of us. That is why 90 percent of them say that in an end-of-life scenario, they would not want cpr. Not only is it unlikely to help, but it generally breaks the patients’ ribs, filling the last chapter of their lives with a great deal of pain.
But cpr is mild compared to some other end-of-life procedures.
“I think a lot of times, we’re doing things to people that we wouldn’t do to a terrorist,” Murray said.
One such procedure is intentionally paralyzing patients so they can be attached to a breathing machine. Unless they are paralyzed, their bodies involuntarily fight against the rhythm of the machine. Dr. Murray explains: “So what happens is you have a person that is fighting, fighting, fighting, fighting, and you can’t get air in and out of them, so you paralyze them. But it doesn’t mean they’re asleep. They’re not asleep. They are completely helpless, and yet they are aware of everything that’s going on around them.”
Doctors see how agonizing this induced paralysis is for patients. That is why 87 percent of them say that if their brains were damaged, they would not want to be put on mechanical ventilation.
Not the Only Life
The problem is sometimes less about people having too much faith in end-of-life procedures than it is about patients and doctors alike being caught in a medical system that encourages excessive treatment. In either case, many patients receive treatments that accomplish little.
Dr. Murray draws on his own background in medicine to summarize his powerful point: “It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. … If there is a state-of-the-art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. … Like my fellow doctors.”
The Bible says “it is appointed” that all people will die (Hebrews 9:27). We don’t have to fear that inevitability. And we don’t have to fill our final weeks or months with invasive, expensive and futile treatments, clinging to this life as if it is the only one there is. God makes clear that the richness of what comes next eclipses this life by many orders of magnitude: “Eye hath not seen, nor ear heard, neither have entered into the heart of man, the things which God hath prepared for them that love him”
(1 Corinthians 2:9).
God also said, through the Apostle Paul, that “the sufferings of this present time are not worthy to be compared with the glory which shall be revealed in us” (Romans 8:18). That future existence will be so astounding that, for the most part, this current life will not even “be remembered” (Isaiah 65:17).
If we reject the unrealistic expectations the media have given us about what doctors can accomplish, and if we learn from the experience of the growing number of doctors like Friedlander, Murray and Blecker who don’t have faith in “futile care” end-of-life procedures, then, when the time comes, we might be inclined to opt out of certain procedures—even to accept death as they aim to: with gentle dignity.